You’ve seen it on head CT reports. “The patient has a collection of extra-axial blood…” Then it goes on to describe the location and size of a subdural hematoma. But why is it called “extra-axial?”
The answer lies in the embryology of the central nervous system. Yes, it’s been a long time since any of us have read anything about that. Early animals had a straight neural tube, which slowly evolved into a brain and spinal cord. This is known as the axis of the nervous system.
The brains of early vertebrates developed at the end of the neural tube, and were oriented in the same longitudinal axis as the rest of it. As brains got bigger, a 90 degree bend occurred at the cephalic flexure.
So in humans, there is a difference between the body axis and the brain axis. But the brain axis is what really counts. This means that any blood outside of the brain axis is defined as extra-axial.
Bottom line: Extra-axial blood is defined as any bleeding outside of the brain parenchyma. This includes subdural and epidural hematomas, and subarachnoid hemorrhage. It does not include any intraparenchymal bleeding like contusions or hematomas.
The intraosseous access device (IO) has been a lifesaver by providing vascular access in patients who are difficult IV sticks. In some cases, it is even difficult to draw blood in these patients by a direct venipuncture. So is it okay to send IO blood to the lab for analysis during a trauma resuscitation?
A study using 10 volunteers was published last year (imagine volunteering to have an IO needle placed)! All IO devices were inserted in the proximal humerus. Here is a summary of the results comparing IO and IV blood:
- Hemoglobin / hematocrit – good correlation
- White blood cell count – no correlation
- Platelet count – no correlation
- Sodium – no correlation but within 5% of IV value
- Potassium – no correlation
- Choloride – good correlation
- Serum CO2 – no correlation
- Calcium – no correlation but within 10% of IV value
- Glucose – good correlation
- BUN / Creatinine – good correlation
Bottom line: Intraosseous blood can be used if blood from arterial or venous puncture is not available. Discarding the first 2cc of marrow aspirated improves the accuracy of the lab results obtained. The important tests (hemoglobin/hematocrit, glucose) are reasonably accurate, as are Na, Cl, BUN, and creatinine. The use of IO blood for type and cross is not yet widely accepted by blood banks, but can be used until other blood is available.
Reference: A new study of intraosseous blood for laboratory analysis. Arch Path Lab Med 134(9):1253-1260, 2010.